Amisulpride-induced tardive dyskinesia

A case of dose-dependent lithium-induced tardive dyskinesia

Tardive dyskinesia (TD) is a serious side effect that manifests itself mainly with choreiform and athetotic movement disorders, and generally occurs in the long term during antipsychotic treatments and is generally irreversible. We report a 67-year-old female patient having a diagnosis of Bipolar Disorder (BD) for 25 years, receiving 1200 mg/day lithium monotherapy for 10 years and in remission. The patient had been showing signs of TD-like syndrome for the last 6 months. Because the patient responded to lithium well and because other treatment options for TD were unsuccessful, the lithium dose was reduced to 600 mg/day and the patient was monitored. Three months after the dose reduction, the patient's remission state continued, and the TD findings regressed. TD mainly due to antipsychotics is known as irreversible. This case suggests that lithium-induced TD may be reversible in a dose-dependent manner.

Amisulpride withdrawal akathisia responding to aripiprazole with propranolol in first-onset psychosis: a case report

BACKGROUND

Akathisia tends to develop as an early complication of antipsychotic treatment in a dose-dependent manner. Although withdrawal akathisia has been reported after the discontinuation or dose reduction of typical antipsychotic drugs, akathisia following atypical antipsychotic drug withdrawal remains a rare phenomenon.

CASE PRESENTATION

A 24-year-old woman with an acute psychotic episode was admitted and initially treated with aripiprazole. The aripiprazole dose was titrated up to 30 mg/day over 9 days and maintained for the next 3 days; however, her psychotic symptoms persisted without change. She was switched to amisulpride, with the dose increased over 2 weeks to 1000 mg/day. Subsequently, although the patient's psychotic episode subsided, her serum prolactin levels increased markedly. After discharge, the amisulpride dose was increased to 1200 mg/day owing to auditory hallucinations and was maintained with quetiapine (100-200 mg/day) and benztropine (1 mg/day) for 13 weeks. Given the potential for hyperprolactinemia as a side effect, the amisulpride dose was reduced to 800 mg/day concurrently with the discontinuation of benztropine; however, these changes resulted in severe restlessness without other extrapyramidal symptoms. The withdrawal akathisia disappeared over 2 weeks after switching to aripiprazole (10 mg/day) with propranolol (40 mg/day) and the patient's prolactin levels had normalized after 6 months of aripiprazole monotherapy.

CONCLUSIONS

The present case highlights the potential for the development of withdrawal akathisia when the dose of amisulpride is tapered abruptly. Thus, a slow tapering and careful monitoring are recommended when switching from amisulpride to other antipsychotic drugs. Furthermore, this case suggests that changing the regimen to aripiprazole with propranolol may be a potential option for amisulpride withdrawal akathisia superimposed on pre-existing hyperprolactinemia.

Lithium monotherapy-induced tardive dyskinesia

Tardive dyskinesia is a movement disorder that develops during the course of long-term treatment with neuroleptic agents and is characterized primarily by choreiform and athetotic movements. We report the case of a 68-year old female suffering from Bipolar disorder, treated with lithium monotherapy 600 mg per day (serum levels 0.6) for the last 15 years. While her response was favorable she was rarely visiting the outpatient clinic. Over the last few months she developed a tardive dyskinesia-like syndrome. To our knowledge this is the first reported case of tardive dyskinesia with lithium monotherapy at low dosages.

Update on the Pharmacological Treatment of Tics with Dopamine-Modulating Agents

More than 40 years of research and clinical practice have proven the effectiveness of dopamine receptor antagonists in the pharmacological treatment of tics. A blockade of the striatal dopamine-D2 receptors is mainly responsible for their tic-reducing effect. A broad spectrum of dopamine-modulating agents, such as typical and atypical antipsychotics, but also dopamine receptor agonists are used with an immanent discord between experts about which of them should be considered as first choice. The present Review outlines the state of the art on pharmacological treatment of tics with dopamine-modulating agents by giving an systematic overview of studies on their effectiveness and a critical discussion of their specific adverse effects. It is considered as an update of a previous review of our research group published in 2013. The Review closes with a description of the current resulting treatment recommendations including the results of a first published revised survey on European expert's prescription preferences. Based on the enormously growing evidence on its effectiveness and safety, aripiprazole currently seems to be the most promising agent in the pharmacological treatment of tics. Furthermore, benzamides (especially tiapride), which are commonly used in Europe, have proven their excellent effectiveness-tolerability profile over decades in clinical practice and are therefore also highly recommended for the treatment of tics. Nevertheless, pharmacological treatment of tics remains an indiviual choice depending on each patient's own specific needs.

Tardive dyskinesia with low dose amisulpride

In recent years, there has been an increasing trend to use amisulpride in the treatment of dysthymia and also as an adjunct treatment in patients with major depression. At low doses (50 mg), amisulpride preferentially blocks presynaptic auto receptors, enhances dopamine release, and therefore acts as a dopaminergic compound able to resolve the dopaminergic hypo activity that characterizes depression. Based on experimental data, amisulpride is the drug of choice for dopaminergic transmission disorders, both in depression and in schizophrenia. This case highlights the development of dyskinesia in a depressed patient treated with low dose amisulpride and fluvoxamine.

Can atypical antipsychotics improve tardive dyskinesia associated with other atypical antipsychotics? Case report and brief review of the literature

Tardive dyskinesia (TD) is a devastating adverse effect of long-term antipsychotic drug treatment. Atypical antipsychotics produce less TD, and it has been shown that they may have a therapeutic effect on pre-existing TD. Here, we report a case of olanzapine-induced TD which did not improve after switching to risperidone but improved after the addition of quetiapine to risperidone regimen. We also provide a brief review of the reported cases on TD induced by atypical antipsychotics which improved after switching to another atypical agent. It is unclear whether some atypical antipsychotics are more effective than others in the treatment of TD. Differences in this property and the underlying mechanism require further study.

Quetiapine reverses altered locomotor activity and tyrosine hydroxylase immunoreactivity in rat caudate putamen following long-term haloperidol treatment

Haloperidol (HAL) is a typical antipsychotic drug and known to cause extrapyramidal symptoms (EPS) that may be associated with the blockade of dopamine D2-receptors in nigrostriatal pathway by the drug. In contrast, quetiapine (QTP) is an atypical antipsychotic drug that has the lowest incidence of producing EPS in patients with schizophrenia, while improving psychosis symptoms. In the present study, we investigated the possibility of reversing the HAL-induced changes in locomotor activity and in striatal tyrosine hydroxylase (TH) of rats. Rats were administered HAL (2mg/kg/day, p.o.) for 3 months, followed by vehicle (VEH), QTP (10mg/kg/day), HAL, or HAL+QTP for another 5 weeks. The locomotor activity and TH immunoreactivity of the rats were measured. Chronic administration of HAL caused significant increase in locomotor activity and lower levels of TH immunoreactivity in the caudate putamen of the striatum. When the long-term haloperidol treatment was removed, the change in TH immunoreactivity was normalized, while the HAL induced high level of locomotor activity was returned to normal level only in the rats that stopped HAL consumption and received QTP treatment. In the substantia nigra and ventral tegmental areas, all rats showed comparable numbers of TH-positive cell bodies, which had no shrinkage. These results support a previously proposed relationship between EPS and TH levels in the striatum and provide valuable preclinical information towards understanding why QTP produces a lowest incidence of EPS among antipsychotics and has been used to treat EPS caused by other antipsychotics, and eventually establish a principle of treating EPS.